Abstract
Introduction: Pregnancy in patients with advanced heart failure requiring left ventricular assist device (LVAD) support is risky and discouraged, though there are cases of successful deliveries. Hypothesis: A 29-year-old G3P2002 female with history of embolic cerebrovascular accident, postpartum hemorrhage, peripartum cardiomyopathy status-post HeartMate 3 (HM3) LVAD, became pregnant after intrauterine device dislodgement. She elected to continue the pregnancy against the advice of maternal-fetal medicine (MFM). A multidisciplinary team convened to plan for delivery. Methods: Warfarin and sacubitril-valsartan were stopped due to teratogenicity. Therapeutic anticoagulation with enoxaparin injections was started. Aspirin was continued. Low-dose digoxin was added for right ventricular support. A multidisciplinary team involving anesthesiology, MFM, and advanced heart failure (AHF) was convened. Through patient-centered shared decision-making, cesarean delivery was planned for 36 weeks. She was seen by MFM and AHF every two weeks with LVAD speed optimization under transthoracic echocardiogram (TTE) guidance and anti-Xa monitoring. Results: The patient was electively admitted at 35 weeks for pre-delivery optimization. Enoxaparin was switched to an unfractionated heparin infusion. Betamethasone was administered to facilitate fetal lung maturation. Twice-daily fetal non-stimulation tests were performed. LVAD speed was optimized with TTE guidance. Continuous hemodynamic monitoring was performed perioperatively with a Swan-Ganz catheter and arterial line. Femoral veno-arterial sheaths were placed in case extracorporeal membrane oxygenation was needed. Anesthesia was administered via spinal-epidural approach. LVAD speed was modulated as needed. A healthy neonate was delivered by cesarean section without complication at 36 weeks and 3 days. Conclusions: Pregnancy during LVAD support remains an extremely high-risk clinical situation, though this case demonstrates that it is possible to carry such a pregnancy to near-term.
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